Healthcare Provider Details

I. General information

NPI: 1306377395
Provider Name (Legal Business Name): BRENDA JO WALKER OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E JACKSON AVE
RIVERTON WY
82501-3866
US

IV. Provider business mailing address

1202 E JACKSON AVE
RIVERTON WY
82501-3866
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-4337
  • Fax: 307-856-0851
Mailing address:
  • Phone: 307-856-4337
  • Fax: 307-856-0851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 347
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: